背景:尽管与改善患者预后有明确的关联,国家综合癌症网络(NCCN)指南的依从性仍然次优。我们试图评估患者(PC)的影响,操作(OC),和医院特征(HCs),以及不符合NCCN结肠癌指南的健康社会决定因素(SDoH)。
方法:从国家癌症数据库中确定了2004-2017年接受I-III期结肠癌治疗的患者。进行了多层次多变量回归分析,以确定与接受NCCN依从性护理相关的因素,以及量化由PC解释的方差比例,OC,HC,和sdoh。
结果:在1,319家医院接受治疗的468,097名结肠癌患者中,四分之一的患者没有接受符合NCCN的治疗(n=122,170,26.1%).关于回归分析,年龄较大(0.96,95%CI0.96-0.96),女性(0.97,95%CI0.96-0.99),黑人种族(0.96,95%CI0.94-0.98),更高的Charlson-Deyo评分(0.84,95%CI0.82-0.86),肿瘤分期≥II期(0.42,95%CI0.40-0.44),肿瘤分级≥3级(0.33,95%CI0.32-0.34)与接受符合NCCN标准的治疗的几率较低相关(所有p值<0.05).医院容量较高(1.02,95%CI1.02-1.03),微创或机器人手术入路(1.26,95%CI1.23-1.29),充分(≥12)淋巴结评估(3.46,95%CI3.38-3.53),私人保险状况(1.33,95%CI1.26-1.40),医疗保险状况(1.42,95%CI1.35-1.49),和较高的教育状态(1.06,95%CI1.02-1.09)与接受符合NCCN的护理的较高几率相关(所有p值<0.05).总的来说,PC贡献了36.5%,HCs贡献了1.3%,OC对指南依从性护理的变化贡献了12.9%;SDoH仅对接受NCCN依从性护理的变化贡献了3.6%。
结论:结肠癌患者NCCN依从性治疗的差异主要归因于患者和外科医生水平的因素,而SDoH与较小比例的变异相关。
BACKGROUND: Despite an established association with improved patient outcomes, compliance with National Comprehensive Cancer Network (NCCN)
guidelines remains suboptimal. We sought to assess the effect of patient characteristics (PCs), operative characteristics (OCs), hospital characteristics (HCs), and social determinants of health (SDoH) on noncompliance with NCCN
guidelines for colon cancer.
METHODS: Patients treated for stage I to III colon cancer from 2004 to 2017 were identified from the National Cancer Database. Multilevel multivariate regression analysis was performed to identify factors associated with receipt of NCCN-compliant care and quantify the proportion of variance explained by PCs, OCs, HCs, and SDoH.
RESULTS: Among 468,097 patients with colon cancer treated across 1319 hospitals, 1 in 4 patients did not receive NCCN-compliant care (122,170 [26.1%]). On regression analysis, older age (odds ratio [OR], 0.96; 95% CI, 0.96-0.96), female sex (OR, 0.97; 95% CI, 0.96-0.99), Black race (OR, 0.96; 95% CI, 0.94-0.98), higher Charlson-Deyo score (OR, 0.84; 95% CI, 0.82-0.86), tumor stage ≥II (OR, 0.42; 95% CI, 0.40-0.44), and tumor grade ≥ 3 (OR, 0.33; 95% CI, 0.32-0.34) were associated with lower odds of receiving NCCN-compliant care (all P values <.05). Higher hospital volume (OR, 1.02; 95% CI, 1.02-1.03), minimally invasive or robotic surgical approach (OR, 1.26; 95% CI, 1.23-1.29), adequate (≥12) lymph node assessment (OR, 3.46; 95% CI, 3.38-3.53), private insurance status (OR, 1.33; 95% CI, 1.26-1.40), Medicare insurance status (OR, 1.42; 95% CI, 1.35-1.49), and higher educational status (OR, 1.06; 95% CI, 1.02-1.09) were associated with higher odds of receiving NCCN-compliant care (all P values <.05). Overall, PCs contributed 36.5%, HCs contributed 1.3%, and OCs contributed 12.9% to the variation in
guideline-compliant care, while SDoH contributed only 3.6% of the variation in receipt of NCCN-compliant care.
CONCLUSIONS: The variation in NCCN-compliant care among patients with colon cancer was largely attributable to patient- and surgeon-level factors, whereas SDoH were associated with a smaller proportion of the variation.